Fatal Accident Inquiry into the death of Declan Hainey

Summary of the Determination by Sheriff Ruth Anderson QC, Sheriff of North Strathclyde, following a Fatal Accident Inquiry held at Paisley into the circumstances of the death of Declan Hugh Hainey.

Declan Hugh Hainey, who was born on 17 April 2008, died at 45 Bruce Road, Paisley between 1 July 2009 and 31 August 2009. The precise date of his death is not known and the cause of death is unascertained. However, the prolonged neglect of Declan by his mother and sole carer Kimberley Hainey was at least a contributory factor in his death.

Kimberley Hainey was found guilty in December 2011 of the murder of her son, but she appealed and in April 2013 the Court of Criminal Appeal quashed that conviction.

No motion was made for a retrial, but the Crown petitioned for a Fatal Accident Inquiry, which commenced on 12 May 2014 and was heard over some 36 days between then and 22 July 2014.

Sheriff Anderson identified the following factors whereby Declan’s death might have been avoided.

If the agencies involved in the information gathering process pre-birth and post-birth had obtained all the information which was available to them (including medical records), assessed the risk factors realistically, and put in place Child Protection measures which would have resulted in continued monitoring and assessment over a longer period of time. This would have resulted in the case being subject to regular inter-agency review and closer scrutiny by both Social Workers and Health Visitors. The case would not have been closed subsequently without a formal inter-agency review.

If there had been comprehensive communication of reports, assessment forms and minutes of the various meetings which took place both pre and post birth to the other agencies involved in the case after it was closed to the Social Work team at Royal Alexandria Hospital. In particular Health Visitors and Family Matters should have been provided with all the information available on Kimberley Hainey and Declan. Had they been so, then the Health Visitors would have categorized the case as one requiring ‘intensive’ as opposed to ‘additional’ support, and would have called for more intensive social work involvement. Family Matters in turn would have referred the case to the Area Team of the Social Work Department prior to Declan’s first birthday with a view to Child Protection measures being taken and /or a referral to the Reporter being made.

If the medical information relating to Kimberley Hainey’s long history of drug and alcohol abuse, together with details of her psychiatric history and inpatient stays at Dykebar Hospital had been gathered by Social Work at the Royal Alexandria Hospital in early 2008, and passed to all social work and health staff who had continuing responsibility for Declan. Had the available information been obtained, it would have contributed in April 2008 to a more realistic assessment of the risks which existed in relation to Kimberley Hainey’s ability to care for her son and would have continued to be an important factor in any continuing assessment process.

If there had been proper, professional inter-agency and intra-agency communication among social work and health staff responsible for the case. When there is comprehensive intra-agency communication then informed decisions can be taken by those in senior positions and action plans produced which have meaning, clarity, and detail, including instructions as to individual responsibility and clear timetabling.

Having determined that on the balance of probabilities neglect was a contributory factor, the following defects in the system contributed to Declan’s death:

There was no system in place whereby one of the agencies responsible for Declan’s well-being was in overall charge and there was no system whereby one named individual was responsible for coordinating all available information. This defect resulted in no formal inter-agency meetings taken place, especially in the period from February 2009. Had such systems existed then those responsible for the care of Declan would have been aware of all that was happening and all that was not happening and steps would have been taken to protect him from the risks resulting from Kimberley Hainey’s inability to take proper care of her son.

There was no system in place in relation to obtaining medical information. There was a fundamental lack of knowledge by Social Work staff at the Royal Alexandria Hospital as to what information they were entitled and how they might obtain it. As has been determined, had such information been available, there would have been a material difference in approach to the case by both Family Matters and Health Visitors and decisions taken in the initial assessment process would have resulted in more protection for Declan.

The following four factors are relevant and recommendations have been made in respect of these:

Staffing levels in Social Work and Health Services,

Action to be taken when a Notification of Concern in relation to an unseen child is received by a social work department,

The distribution of medical information to those working in cases where there are children of substance misusing parents or care

Mandatory training of general practitioners in the guidance and protocols relating to child protection.

“When the findings and recommendations of an inquiry such as this are produced, the expression ‘lessons have been learned’ is one which is perhaps often used without much thought to its practical application. Some five years have passed since Declan died, and those in positions of management responsibility, as well as all staff, have taken their duties and obligations seriously, and many changes have now been made to remedy defects and tighten procedures and channels of communication. It is appropriate that the Inquiry recognises those improvements and the work that has gone into achieving them and I do so now.”